=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750136941
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SIMPLY MIND OVER MATTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2024
-----------------------------------------------------
Last Update Date | 05/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5540 CENTERVIEW DR STE 204
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27606-8012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-690-6648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6375 SWANNS STATION RD
-----------------------------------------------------
City | SANFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27332-7796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-690-6648
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS OWNER/EMPLOYEE
-----------------------------------------------------
Name | MRS. TABATHA A. TREAGER
-----------------------------------------------------
Credential | LCSW
-----------------------------------------------------
Telephone | 910-690-6648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------